Reducing instrument for spinal surgery

ABSTRACT

An instrument is provided for use in orthopedic surgery for reduction of a connecting member such as a spinal rod toward an implant such as a bone screw. An embodiment of the instrument includes handle portions that are pivotable relative to each other and biased apart, and arm portions pivotable relative to each other and to the handle portions. Distal portions of the arm portions, which may be offset from the arm portions, provide structure for engaging a connecting member and an implant. Squeezing the handle portions force the distal portions of the arm portions together, forcing together the connecting member and the implant. A toothed bar and pawl may be provided to retain the instrument in a squeezed state.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation in part of and claims priority toU.S. patent application Ser. No. 11/043,318, filed Jan. 26, 2005.

BACKGROUND

In orthopedic surgical procedures, it is known to implant devices tosupport bones or other tissue, to correct deformities, to hold tissuesin position for healing after injuries or other surgery, and for otherpurposes relating to orthopedic health. For example, where correction ofa scoliotic or other abnormal curvature or misalignment of the spine isdesired, a sturdy rod, plate, or other elongated connecting member canbe placed along one or more vertebral segments to support or hold thesegments in a corrected position. Bone screws, bone hooks or otherfixation implants are attached to vertebrae and connected to theconnecting member to secure the connecting member along the spinalcolumn.

Commonly, the fixation implants and the connecting member(s) are placedseparately, that is, they are not connected together prior toimplantation in the body. For example, bone screws may be implanted intovertebrae first, connectors may be placed on or around the screws (ifnecessary), and then the connecting member may be placed into the body.The connecting member may be contoured prior to insertion to approximatethe curvature desired, or it may be contoured after placement adjacentthe spine. In cases where a connecting member and bone screws or otherfixation elements are separately placed, the connecting member andscrews may be required to be forced toward each other for connection.The process of moving the connecting member and fixation elements towardeach other for connection is generally termed “reduction.”

Reduction can be accomplished by hand, although the environment andclose quarters of a surgical site can make reduction by hand quitedifficult. While instruments have been developed to provide a mechanicaladvantage in reducing or positioning the connecting member relative toan anchor, there remains a need for reducing instruments which aremaneuverable relative to the anchor and connecting member to facilitateinsertion and manipulation of the connecting member and anchor throughthe incision or portal in which the reducing instrument is positioned.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view of an embodiment of an instrument accordingto the present invention.

FIG. 2 is an exploded perspective view of the embodiment shown in FIG.1.

FIG. 3 is another view of the embodiment shown in FIG. 1 insubstantially a reverse perspective from that shown in FIG. 1, withcertain parts shown in exploded fashion.

FIG. 4 is a top plan view of an embodiment of an arm portion of theembodiment shown in FIG. 1.

FIG. 5 is a side plan view of the embodiment shown in FIG. 4.

FIG. 6 is a partial cross-sectional view of the embodiment shown in FIG.4, taken along the line 6-6 in FIG. 5 and viewed in the direction of thearrows.

FIG. 7 is a top plan view of an embodiment of an arm portion of theembodiment shown in FIG. 1.

FIG. 8 is a cross-section view of the embodiment shown in FIG. 7, takenalong the line 8-8 in FIG. 7 and viewed in the direction of the arrows.

FIG. 9 is a side plan view of the embodiment shown in FIG. 7.

FIG. 10 is a bottom plan view of the embodiment shown in FIG. 7.

FIG. 11 is a side view of an embodiment of an instrument in relation toan orthopedic rod and an orthopedic implant.

FIG. 12 is a side view of the embodiment shown in FIG. 11 in relation toa reduced orthopedic rod.

FIG. 13A is a perspective view of arm portions of another embodiment ofan instrument according to the present invention in relation to anorthopedic rod and an orthopedic implant.

FIG. 13B is a side view of the embodiment shown in FIG. 13A in relationto an orthopedic rod and an orthopedic implant.

FIG. 14A is a perspective view of arm portions of another embodiment ofan instrument according to the present invention in relation to anorthopedic rod and an orthopedic implant.

FIG. 14B is a side view of the embodiment shown in FIG. 14A in relationto an orthopedic rod and an orthopedic implant.

FIG. 15A is a perspective view of arm portions of another embodiment ofan instrument according to the present invention in relation to anorthopedic rod and an orthopedic implant.

FIG. 15B is a side view of the embodiment shown in FIG. 15A in relationto an orthopedic rod and an orthopedic implant.

FIG. 16A is a perspective view of arm portions of another embodiment ofan instrument according to the present invention in relation to anorthopedic rod and an orthopedic implant.

FIG. 16B is a side view of the embodiment shown in FIG. 16A in relationto an orthopedic rod and an orthopedic implant.

FIG. 17 is a side view of another embodiment of an instrument accordingto the present invention.

FIG. 18 is a perspective view of an arm portion of another embodiment ofan instrument according to the present invention.

FIG. 19 is side view of arm portions of another embodiment of aninstrument according to the present invention in relation to anorthopedic rod and an orthopedic implant.

FIG. 20 is side view of arm portions of another embodiment of aninstrument according to the present invention in relation to anorthopedic rod and an orthopedic implant.

DESCRIPTION OF THE ILLUSTRATED EMBODIMENT

For the purposes of promoting an understanding of the principles of theinvention, reference will now be made to the embodiment illustrated inthe drawings and specific language will be used to describe the same. Itwill nevertheless be understood that no limitation of the scope of theinvention is thereby intended. Any such alterations and furthermodifications in the illustrated device, and any such furtherapplications of the principles of the invention as illustrated herein,are contemplated as would normally occur to one skilled in the art towhich the invention relates.

Referring generally to the figures, there is shown a reducing instrument20 that is removably engageable to an implant (e.g. a bone screw orother anchor) and operable to move a rod or other elongated connectingmember and the implant toward each other. Reducing instrument 20includes handle portions 22 and 24, springs 26 and 28, and arm portions30 and 32. Use of instrument 20 allows good visibility of the implantand remote or sideward positioning of the reducing instrument inalignment with the implant.

Handle portion 22 is generally elongated, having a generally proximalend 40 and a generally distal end 42. Proximal end 40 may be pivotallyconnected to a toothed bar 44. Toothed bar 44 may be pivotally connectedat 46 to a ratchet post 48, having a slot 49, which is pivotallyconnected to proximal end 40 of handle portion 22. Handle portion 22 mayalso have a thickened portion 50 to provide a guide for the surgeon'shand, to provide a more stable or secure connection to bar 44 and/orratchet post 48 if they are present, or for other purposes. Handleportion 22 also includes hole 52 through which handle portion 22 can beconnected to handle portion 24. Hole 52 is formed through apart-circular portion 53 that extends from an inside surface of handleportion 22. Portion 53 is thinner than handle portion 22 and issubstantially centered on handle portion 22. Hole 52 is generallybetween proximal end 40 and distal end 42; in the illustrated embodimenthole 52 is relatively close to or adjacent distal end 42. A forkedportion 54 is provided at distal end 42, for connecting to an armportion, as further described below. Forked portion 54 includes holes 55a and 55 b, one of which (e.g. 55 a) may be threaded.

Handle portion 24 is generally elongated, having a generally proximalend 60 and a generally distal end 62. Proximal end 60 may include a pawl64 for engaging toothed bar 44. Further, a release lever 66 having ahandle 68 and a contact surface 70 may be pivotally connected toproximal end 60. Pressing on handle 68 causes lever 66 to pivot so thatcontact surface 70 pushes against bar 44 to disengage bar 44 from pawl64, allowing handle portions 22 and 24 to be spaced apart. Handleportion 24 also includes a groove 72 that makes distal end 62 generallydivided or forked. Holes 74 a and 74 b through which handle portion 24can be connected to handle portion 22 are provided generally betweenproximal end 60 and distal end 62, and in the illustrated embodimentadjacent distal end 62. Holes 74 a and 74 b are formed throughpart-circular portions 76 a and 76 b that extend from an inside surfaceof handle portion 24. Forked distal end 62 also includes holes 78 a and78 b for connecting to an arm portion, as further described below. Oneor both of holes 78 a and 78 b (e.g. 78 a) may be threaded.

In the illustrated embodiment, two leaf springs 26 and 28 are providedto bias handle portions 22 and 24 apart. Spring 26 is attached at oradjacent to an end 90 to handle portion 22 relatively close to proximalend 40, as by a set screw 91 or other connector. Spring 28 is attachedat or adjacent to an end 92 to handle portion 24 relatively close toproximal end 60, as by a set screw 91 or other connector. Springs 26 and28 may interengage, for example via a tongue-and-groove type ofengagement. In that configuration, spring 26 may have a tongue portion94 at the end opposite end 90, and spring 28 may have a groove 96 at theend opposite end 92. When springs 26 and 28 are attached to handleportions 22 and 24, tongue 94 extends into and/or through groove 96. Inone particular embodiment, spring 26 may have a tab 98 at or adjacent toend 90 that can be inserted in slot 49 of ratchet post 46. Tab 98 actsas a spring to apply a force on bar 44 to maintain bar 44 in contactwith pawl 64. It will be seen that only one leaf spring, such as spring26 (with or without tongue 94 or tab 98) may be provided for biasinghandle portions 22 and 24 apart, or one or more coil or other springsmay be provided, or other appropriate structure for biasing handleportions 22 and 24 apart.

Arm portion 30 is an elongated piece having a proximal end 110 and adistal end 112. A relatively thin part-circular portion 114 is providedat or adjacent proximal end 110 with a hole 116 for connecting to hole54 of handle portion 22. Arm portion 30 also includes a grooved orforked portion 118 generally between proximal end 110 and distal end 112and in the illustrated embodiment adjacent proximal end 112. Holes 120 aand 120 b through which arm portion 30 can be connected to arm portion32 are provided in forked portion 118. Holes 120 a and 120 b are formedthrough part-circular portions 121 a and 121 b that extend from aninside surface of arm portion 30. One or both of holes 120 a and 120 b(e.g. 120 a) may be threaded.

Distal end 112 has a substantially U-shaped portion 122 having extensionportions 124 and 126 and cross-pieces 128 and 130. In the illustratedembodiment, extension portions 124 and 126 are substantially parallel toeach other, and are substantially perpendicular to cross-pieces 128 and130. Cross piece 128, in one embodiment, is essentially a lateralextension of the main part of arm portion 30, and may have anindentation 129 through which a screwdriver or other tool can beextended to reach an implant, as for example to apply a locking membersuch as a set screw to the implant. Cross-piece 130 may include a tab132 generally extending toward cross-piece 128, which may be at leastpartially curved, e.g. to provide a surface with a curvatureapproximating that of an orthopedic rod. Cross-piece 130 may alsoinclude an indentation 131 similar to indentation 129 and for a similarpurpose. Extension portions 124 and 126 include substantiallypart-cylindrical hollows 134 and 136, respectively. Hollows 134 and 136are linear, i.e. the axes of the cylinders of which hollows 134 and 136are a part are collinear, and hollows 134 and 136 may be of a size andcurvature to accommodate an orthopedic rod, e.g. forming a substantiallysemi-circular (180-degree) section. In a particular embodiment, armportion 30 has a longitudinal axis L. U-shaped portion 122 is laterallyoffset from axis L, and may be offset in a direction substantiallyperpendicular to axis L. U-shaped portion 122 may also be angled withrespect to axis L, in a particular embodiment so that U-shaped portion122 bends toward arm portion 32. Such an angle α may be about 160degrees in one embodiment.

Arm portion 32 is an elongated piece having a proximal end 140 and adistal end 142. A relatively thin part-circular portion 144 is providedat or adjacent proximal end 140 with a hole 145 for connecting to holes78 a and 78 b of handle portion 24. Arm portion 30 also includes anotherrelatively thin part-circular portion 146 with a hole 148 generallybetween proximal end 140 and distal end 142 and extending from an insidesurface of arm portion 32, and in the illustrated embodiment adjacentproximal end 142. Portion 146 fits within forked portion 118 of armportion 30 so that hole 148 communicates with holes 120 a and 120 b.

Distal end 142 has a substantially U-shaped portion 152 having extensionportions 154 and 156 and cross-piece 158. In the illustrated embodiment,extension portions 154 and 156 are substantially parallel to each other,and are substantially perpendicular to cross-piece 158. Cross piece 158,in one embodiment, is essentially a lateral extension of the main partof arm portion 32. Extension portions 154 and 156 include protrusions160 and 162 that may be substantially cylindrical. Protrusions 160 and162 may be substantially linear, i.e. the axes of protrusions 160 and162 are collinear, and may be relatively thin or short. Protrusions 160and 162 are for connecting to indentations or hollows in an implant, andtherefore they may be configured to accommodate the shape, depth and/orother features of such indentations or hollows.

In a particular embodiment, arm portion 32 has a longitudinal axis M.U-shaped portion 152 can be laterally offset from axis M, and may beoffset in a direction substantially perpendicular to axis M. As withportion 122 of arm 30, U-shaped portion 152 could also be angled withrespect to axis M in another plane.

As has been suggested above, instrument 20 is assembled generally asfollows. Handle portions 22 and 24 are connected by inserting thinportion 53 of handle portion 22 into grooved portion 72 of handleportion 24 so that hole 52 of handle portion 22 communicates with holes74 a and 74 b of handle portion 24. An axle, for example a rivet, pin orset screw (e.g. set screws 170 in FIG. 3), can be inserted through holes52, 74 a and 74 b and secured so that handle portions 22 and 24 canpivot with respect to each other around such an axle. In an embodimentin which at least one of holes 52, 74 a and 74 b are at least partiallythreaded, a set screw may be used as the axle, with the relativeadvantage that the interacting threads tend to retain the set screwwithin the holes. In other embodiments, a separate retaining piece, suchas a ring to fit into a groove of an axle, or an additional step toretain the axle within the holes, such as swaging or peening part of theaxle, can be included.

It will be seen that connection of handle portions 22 and 24 shouldaccount for connections of associated parts that may be present. Forexample, in embodiments in which handle portion 22 includes toothed bar44 and handle portion 24 includes pawl 64, connection of handle portions22 and 24 should ensure that bar 44 and pawl 64 connect. In embodimentsincluding lever 66, lever 66 should be proximate to or abut bar 44. Asanother example, in embodiments in which handle portions 22 and/or 24include springs, connection of handle portions 22 and 24 should ensurethat the one or more springs are proximate to or abut each other or theopposing handle portion so that biasing apart of the handle portions 22and 24 occurs. In one particular embodiment, as noted above leaf springs26 and 28 should be arranged so that tongue 94 of spring 26 is at leastpartially within groove 96 of spring 28.

Arm portions 30 and 32 are connected to each other, and each isconnected to one of the handle portions 22 and 24, substantially asdescribed above. Thin portion 146 of arm portion 32 is inserted intogrooved portion 118 of arm portion 30 so that hole 148 of arm portion 32communicates with holes 120 a and 120 b of arm portion 30. An axle asdescribed above can be inserted through holes 148, 120 a and 120 b andsecured so that arm portions 22 and 24 can pivot with respect to eachother around such an axle. A set screw (e.g. set screws 170 in FIG. 3)may be used as such an axle, particularly in embodiments in which atleast one of holes 148, 120 a and 120 b are at least partially threaded.Arm portion 30 is connected to handle portion 22 by inserting thinportion 114 of arm portion 30 into the forked end 54 of handle portion22, so that hole 116 of arm portion 30 communicates with holes 55 a and55 b of handle portion 22. An axle as described above can be insertedthrough holes 116, 55 a and 55 b and secured so that arm portion 30 andhandle portion 22 can pivot with respect to each other around such anaxle. A set screw (e.g. set screws 170 in FIG. 3) may be used as such anaxle, particularly in embodiments in which at least one of holes 116, 55a and 55 b are at least partially threaded. Arm portion 32 is connectedto handle portion 24 by inserting thin portion 144 of arm portion 32into the forked end of handle portion 24, so that hole 145 of armportion 32 communicates with holes 78 a and 78 b of handle portion 24.An axle as described above can be inserted through holes 145, 78 a and78 b and secured so that arm portion 32 and handle portion 24 can pivotwith respect to each other around such an axle. A set screw (e.g. setscrews 170 in FIG. 3) may be used as such an axle, particularly inembodiments in which at least one of holes 145, 78 a and 78 b are atleast partially threaded.

It will be seen that the several portions of embodiments of instrument20 can be connected in a variety of orders. For example, arm portions 30and 32 can be connected to each other, then to individual handleportions 22 and 24, with the final connection being that between handleportions 22 and 24. As another example, handle portions 22 and 24 can beconnected together first, then to arm portions 30 and 32, with armportions 30 and 32 being either separate or already connected. Theinstrument 20 can be assembled as indicated above and in FIGS. 1-3, withdistal portions 112 and 142 of arms 30 and 32 offset to the left whenhandle portion 22 is substantially atop handle portion 24. Thatpositioning occurs when handle portion 22 is directly connected to arm30 and handle portion 24 is directly connected to arm 32. Instrument 20can also be assembled so that arm 30 is directly connected to handleportion 24, and arm 32 is directly connected to handle portion 22. Inthat case, distal portions 112 and 142 of arms 30 and 32 are offset tothe left when handle portion 24 is substantially atop handle portion 22,as in FIGS. 11-12.

In using the illustrated embodiment of instrument 20, it will be seenthat squeezing handle portions 22 and 24 together causes rotation ofhandle portions 22 and 24 with respect to each other, so that theirrespective distal ends 42 and 62 move apart. As distal ends 42 and 62move apart, the proximal parts of arm portions 30 and 32 also moveapart. By virtue of the pivoting connection of arm portions 30 and 32,when the proximal parts of arm portions 30 and 32 move apart, theirrespective distal portions 112 and 142 move together. Thus, by squeezinghandle portions 22 and 24 together, the distal portions 112 and 142 areforced together.

The operation of instrument 20 to engage an implant and rod or otherconnecting member and seat the connecting member in the implant anchorwill now be described with respect to operation on a spinal column.Alternative uses with respect to other bony structures or other tissuescan be made. As with other types of orthopedic surgery, an incision ismade and access is gained to the surgical site. The approach to thesurgical site can be an open approach, i.e. a relatively long incisionwith retraction of underlying tissue. The instrument disclosed hereincan be used in such an approach, or with other surgical techniques.

After access to the surgical site has been obtained, anchors such asthose including a receiver member 180 are inserted into bone tissue.Such anchors may be pre-fitted with receiver member 180 or otherreceiver member embodiment, and such anchors typically include a boneengaging portion 182 and a channel 183 for accommodating part of rod R.Such a channel 183 may point substantially to the side as shown in thefigures, or may open to the back of the anchor, or be otherwiseoriented. Such receiver members may also be placed on or over engagingportions after engagement of the engaging portions into bone, and may bemulti-axial, pivotable or otherwise adjustable with respect to suchengaging portions. A connecting member, such as rod R, is inserted intothe surgical site, and placed adjacent one or more of the anchors. Ifnot already present, receiver members 180 may be loosely placed on theconnecting member prior to insertion of the connecting member to thesurgical site. The anchors and connecting member are manipulated so thata part of the connecting member is in or near the each of the anchors.Receiver member 180 can include a pair of branches 184 which generallyform channel 183 therebetween. Instrument 20 may be used with a varietyof anchors or implants, including those known previously in the art andthose disclosed in U.S. patent application Ser. No. 11/000,585 filed onNov. 30, 2004 and Ser. No. 11/000,846 filed Dec. 1, 2004 and,respectively entitled SIDE-LOADING ADJUSTABLE BONE ANCHOR andSIDE-LOADING BONE ANCHOR, which are incorporated herein by reference intheir entireties.

After engagement of the implant to a vertebra, rod R is positionedadjacent the implant. It is contemplated that a number of implants canbe positioned and engaged along the spinal column, and the rod engagedin a channel or other area of one of the implants. Due to misalignmentof vertebrae, misalignment of the implants, or other conditions, the rodmay not be easily or readily positioned in one or more implants.

Once the rod is adjacent an implant into which the rod is to be placedor seated, instrument 20 may be introduced to reduce or force the rodinto the implant. With handle portions 22 and 24 in an unstressed state,i.e. biased away from each other or otherwise spread apart, distal ends112 and 142 of arm portions 30 and 32 are also spread apart. Distal ends112 and 142 are placed around the combination of rod R and receivermember 180, so that distal end 112 is adjacent to or abutting a surfaceof rod R relatively distant from receiver member 180, and distal end 142is adjacent to or abutting a surface of receiver member 180 relativelydistant from rod R. In the embodiment in which distal end 142 includesprotrusion(s) 162, such protrusion(s) 162 are inserted or maneuveredinto hollow(s) or aperture(s) in receiver member 180. In an alternativeembodiment in which receiver member 180 includes one or more sideprotrusions rather than hollow(s), distal end 142 may be provided withone or more hollows 162′, e.g. in extensions 154 and/or 156, toaccommodate such protrusions.

Where protrusion(s) 162 or hollow(s) 162′ are provided and aresubstantially rounded or cylindrical and fit with corresponding parts ofreceiver member 180, as previously described, instrument 20 can pivot orrotate with respect to receiver member 180, as seen in one example inFIGS. 11-12. In that example, a distal portion of arm 32 changes anglewith respect to the anchor or implant, as in FIG. 11 that portion of arm32 is at an oblique angle with respect to engaging portion 182, and inFIG. 12 that portion of arm 32 is substantially parallel to engagingportion 182. The axis of rotation in that example substantiallycorresponds with protrusion(s) 162 or hollow(s) 162′, is different fromthe axes around which arms 22, 24, 30 and 32 pivot, and is substantiallyparallel to the axis of channel 183 of receiver member 180. Suchpivoting or rotation around protrusion(s) 162 or hollow(s) 162′ mayforce rod R generally toward the bone or substantially perpendicular toa bone surface (downward as seen in FIG. 11) and/or generally towardreceiver member 180. In other words, such pivoting may force rod Rgenerally obliquely with respect to a longitudinal axis of implant 180,or in a direction that has at least a component parallel to alongitudinal axis of implant 180. Such pivoting or rotation can occur inthis embodiment as may be necessary for rod reduction.

Handle portions 22 and 24 are then squeezed together, which as discussedabove forces distal ends 112 and 142 of arm portions 30 and 32 towardeach other. Forcing together distal ends 112 and 142 causes rod R andreceiver member 180 to move relative to each other so that they becomenearer to each other. In many cases, the rod will undergo all orsubstantially all of such relative movement, and the implant (which isanchored to a bone) will remain relatively stationary. However, it willbe appreciated that in some uses the surgeon would prefer the bone andimplant to undergo movement toward the rod, for example in some cases ofsignificant vertebral misalignment, and thus instrument 20 can causesuch movement of the implant, perhaps with direct manipulation of thebone by the surgeon.

Squeezing of handle portions 22 and 24 is continued until distal ends112 and 142 of arm portions 30 and 32 force rod R and receiver member180 together to the extent desired by the surgeon. Toothed bar 44 andpawl 64 interact to maintain handle portions 22 and 24 (and thus armportions 30 and 32) in a squeezed state, and keeping them from beingbiased apart if the surgeon's grip should loosen. In this way,instrument 20 can maintain pressure on a rod and implant while thesurgeon rests his or her hand or performs another task. As rod R entersreceiver member 180, distal end 112 of arm portion 30 approaches theimplant (e.g. generally parallel to a bone or bone surface to which theimplant is connected), and specifically branches 184 on either side ofchannel 183 or other area that accommodates the rod. Distal end 112 ofarm portion 30 is configured to be able to force rod R into receivermember 180 to the greatest degree desired, because cross pieces 128 and130 are spaced apart so as to interfere minimally or not at all withbranches 184 of receiver member 180. Thus, as distal end 112 approachesbranches 184 of receiver member 180, branches 184 enter the gaps betweencross pieces 128 and 130, allowing distal end 112 to press the rodtoward or to the back of the implant, if that is desired. Through suchsqueezing of instrument 20 or pivoting of instrument 20 with respect toreceiver member 180, or a combination of the two motions, rod R isreduced into channel 183 of receiver member 180.

Once the rod is positioned as the surgeon desires in the implant, therod is locked into the implant using structure (e.g. set screw, cap,clamp) provided with the implant, as for example by inserting thestructure and an appropriate tool through indentations 129 and 131 tothe implant. Instrument 20 may be removed from contact with the rod andthe implant after such locking, or before if the rod will remain atleast approximately in the position desired by the surgeon. When it isdesired to remove or loosen the contact of instrument 20 with the rodand/or the implant, the surgeon may press lever 68, which pivots to pushtoothed bar 44 away from pawl 64. Springs 26 and 28 then act to pushhandle portions 22 and 24 apart, per their normal bias, and distalportions 112 and 142 of arm portions 30 and 32 come away from the rodand the implant. The surgeon may then move to reduction of the rod intoanother implant, or may remove instrument 20 from the surgical site toperform other tasks or conclude the surgical procedure.

FIGS. 13A-13B illustrate a portion of a reducing instrument 220according to another embodiment. In that embodiment, instrument 220includes arm portions 30 and 232. Instrument 220 may further includehandle portions and springs (not shown for clarity), similar instructure and function to handle portions 22 and 24 and springs 26 and28, and connected as described in with respect to previous embodiments,as are other embodiments described below. Additionally, instrument 220may include a toothed bar and pawl assembly, as previously described.Arm portion 232 is an elongated piece having a proximal end 240 and adistal end 242. It should be appreciated that arm portion 232 connectswith a corresponding handle portion in a substantially similar manner asarm portion 32 connects with handle portion 24.

Distal end 242 has an extension portion 254. Extension portion 254 maygenerally increase in width from a proximal point 254 a to a distalpoint 254 b. In the illustrated embodiment, extension portion 254includes one section of increasing width; however, it should beappreciated that extension portion 254 can be configured differently.Extension portion 254 includes an approximately 90 degree bend in theillustrated embodiment at bend point 260 between a proximal portion 262and a distal portion 264. The extension portion 254 may bend in adirection toward an anchor, with distal portion 264 being substantiallyperpendicular to proximal portion 262. Distal portion 264 includes asection 266, which is generally cylindrical in one particularembodiment, at distal point 254 b. Section 266 can be configured tocontact an anchor, such as anchor 270. It should be appreciated thatinstrument 220 may be used with a variety of anchors or implants.Additionally, section 266 can be larger or smaller to fittingly contactvarious sized channels in various anchors or implants.

In the illustrated embodiment, anchor 270 includes a receiver portion280 and an engaging portion 282. In certain embodiments, receiverportion 280 includes a first channel 283 and a second channel 284. Partof a rod R can be accommodated in one of channels 283 or 284, dependingon which channel is closer to or more exposed to rod R. In theillustrated embodiment, rod R is to be loaded into channel 283, andtherefore section 266 of instrument 220 can be inserted into channel 284in order to reduce or force rod R toward or into channel 283. Receiverportion 280 in the illustrated embodiment is integral with respect toengaging portion 282. A threaded cap (not shown) can thread ontoreceiver portion 280 to hold rod(s) or other elongated members withrespect to receiver member 280.

FIGS. 14A-14B illustrate a portion of instrument 220 used in conjunctionwith an anchor 370 including a receiver member 380 and an engagingportion 382. Anchor 370 is substantially similar in structure andfunction to the anchors previously described herein (e.g. those shown inFIGS. 11-12). Receiver member 380 includes a first channel 383 foraccommodating part of rod R. Such a channel 383 may point substantiallyto the side as shown in the figures, or may open to the back of asimilar anchor, or be otherwise oriented. In certain embodiments,receiver member 380 also includes a second channel 384 for accommodatingpart of segment 266.

FIG. 15A-15B illustrate a portion of another embodiment of a reducinginstrument 420. Instrument 420 includes arm portions 30 and 432.Instrument 420 may further include handle portions and springs (notshown for clarity), similar in structure and function to handle portions22 and 24 and springs 26 and 28. Additionally, instrument 420 mayinclude a toothed bar and pawl assembly, as previously described. Armportion 432 is an elongated piece having a proximal portion 440 and adistal end 442 in the illustrated embodiment. It should be appreciatedthat arm portion 432 connects with a corresponding handle portion in asubstantially similar manner as arm portion 32 connects with handleportion 24.

Distal end 442 includes an extension portion 454. Extension portion 454may generally increase in width from a proximal point 454 a to a distalpoint 454 b. In the illustrated embodiment, extension portion 454includes one section of increasing width; however, it should beappreciated that extension portion 454 can be configured differently.Extension portion 454 includes extension pieces 455 and 456, and a crosspiece 458. In the illustrated embodiment, extension pieces 455 and 456are substantially parallel to each other and to the body of arm 432, andare substantially perpendicular to cross-piece 458. The extension piecesare connected at distal point 454 b with a section 466 that issubstantially cylindrical in the illustrated embodiment. Section 466 isconfigured to contact an anchor, such as anchor 270. Section 466 can belarger or smaller to fittingly contact various sized channels in variousanchors or implants.

In the embodiment illustrated in FIGS. 15A and 15B, instrument 420 isused in conjunction with an anchor 270 including receiver member 280 andengaging portion 282. Extension pieces 455. 456, cross-piece 458, andsection 466 all generally define a gap 468. Gap 468 is sufficientlysized and configured to admit one of the anchor branches defining secondchannel 284 of anchor 270.

FIGS. 16A-16B illustrate a portion of instrument 420 used in conjunctionwith an anchor 370 including receiver member 380 and engaging portion382. Receiver member 380 also includes second channel 384 foraccommodating part of cylindrical segment 466.

FIG. 17 illustrates another embodiment of a reducing instrument 520.Instrument 520 includes handle portions 22 and 24, springs 26 and 28,and arm portions 530 and 532. Additionally, instrument 520 may include atoothed bar 44 and a pawl 64, as previously described. It should beappreciated that arm portions 530 and 532 connect with handle portions22 and 24, respectively, in a substantially similar manner as armportions 30 and 32 connect with the handle portions. Arm portions 530and 532 have proximal ends 530 a and 532 a, and distal ends 530 b and532 b, respectively. Additionally, arm portions 530 and 532 each includesections of curvature 540 and 542, respectively, positioned between theproximal and distal ends. In certain embodiments, the sections ofcurvature prevent interference with various tissues and/or otherstructures or materials within or adjacent to the patient or thesurgical site. Distal ends 530 b and 532 b can be sized and configuredin a manner as previously described to contact and engage an anchor androd or other connecting member and seat the connecting member in theanchor.

In some embodiments, sections 540, 542 are generally positioned in thesame plane as the handle portions and arm portions. In other words,sections of curvature 540, 542 generally open in a direction from onearm portion to the other arm portion. In the illustrated embodiment,section 540 opens towards section 542, and concave portions of sections540 and 542 face in generally the same direction (e.g. the left as shownin FIG. 17). However, it should be appreciated that sections 540, 542can be arranged, oriented or configured differently.

FIG. 18 illustrates a portion of an arm 630 of a reducing instrument inanother embodiment. Arm 630 includes a proximal end (not shown) that maybe similar or identical to ends of arms described above, and a distalend 612. Distal end 612 includes extension portions 624 and 626 (similarto extensions 134 and 136 and those shown in FIGS. 13A, 14A, 15A and16A), which may include part-cylindrical hollows 634 and 636,respectively. Hollows 634 and 636 are linear, e.g. the axes of thecylinders of which hollows 634, 636 are a part are collinear, andhollows 634, 636 may be of a size and curvature to accommodate anorthopedic rod R. In the illustrated embodiment, hollows 634, 636 eachform a substantially quarter-circular (90-degree) section 640, with anadjacent straight segment 642. The absence of a lower lip on one or bothhollows 634, 636, as in the illustrated embodiment, can encourageaccommodation of an angled rod, e.g. one not perpendicular to extensionportions 624 and 626 when their instrument is inserted to the surgicalsite, or other elongated members of various configurations.

FIG. 19 illustrates a portion of a reducing instrument 720 in anotherembodiment. Instrument 720 includes arm portions 30 and 732. Instrument720 may further include handle portions and springs (not shown forclarity), similar in structure and function to handle portions 22 and 24and springs 26 and 28. Additionally, instrument 720 may include atoothed bar and pawl assembly, as previously described. Arm portion 732is an elongated piece having a proximal end 740 and a distal end 742. Itshould be appreciated that arm portion 732 connects with a correspondinghandle portion in a substantially similar manner as arm portion 32connects with handle portion 24. A protrusion 766 is disposed on armportion 732 at distal end 742. In the illustrated embodiment, protrusion766 is spherical; however, it should be appreciated that protrusion 766can be configured differently. Protrusion 766 is configured to contactan anchor 770, similar in configuration to anchor 370. In certainembodiments, anchor 770 can include a recess configured to receive aportion of protrusion 766. In one embodiment, protrusion 766 extends thewidth of arm portion 732. In another embodiment, arm portion 732 mayinclude two extension portions, and a protrusion such as protrusion 766,disposed on each distal end of the extension portions.

FIG. 20 illustrates a portion of a reducing instrument 820 according toanother embodiment. Instrument 820 includes arm portions 30 and 832.Instrument 820 may further include handle portions and springs (notshown for clarity), similar in structure and function to handle portions22 and 24 and springs 26 and 28. Additionally, instrument 820 mayinclude a toothed bar and pawl assembly, as previously described. Armportion 832 is an elongated piece having a proximal end 840 and a distalend 842. It should be appreciated that arm portion 832 connects with acorresponding handle portion in a substantially similar manner as armportion 32 connects with handle portion 24. In the illustratedembodiment, a protrusion 866 is disposed on an anchor 870, similar inconfiguration to anchor 370. Protrusion 866 is shown to be spherical inone embodiment; however, it should be appreciated that protrusion 866can be configured differently. Protrusion 866 is positioned on thereceiver portion of anchor 870, opposite a channel for receiving aportion of an orthopedic rod R or other elongated member. In certainembodiments, the arm portion includes a recess 890 at distal end 842configured to receive a portion of protrusion 866.

In an alternative embodiment, arm portion 832 of reducing instrument 820could include a recess configured to receive a portion of a receivermember of an anchor (e.g. anchor 370). In such an embodiment, the recessin the arm portion would fittingly contact a portion of a receivermember of an anchor, the portion being opposite a channel configured toreceive an orthopedic rod. In such an embodiment, protrusion 866 may beabsent and the recess in the arm portion partially surrounds thereceiver member of the anchor. The recess may include a generallyspherical configuration or another such appropriate configuration. Insuch an embodiment, the recess in the arm portion, and the portion ofthe receiver member contacting the recess in the arm portion, wouldgenerally include similar degrees of curvature so that the arm portionwould fittingly contact the anchor.

The assembly and operation of reducing instruments 220, 420, 520, 720,and 820 is substantially similar to the assembly and operation ofreducing instrument 120 described above. As an example, the arm portionsof the reducing instruments 220, 420, 520, 720, and 820 connect to eachother in a substantially similar manner as arm portions 30 and 32connect together.

Regarding the operation of embodiments of reducing instruments 220, 420,520, 720, and 820, after access to the surgical site has been obtained,anchors such as those including receiver members 280 or 380 are insertedinto bone tissue. Such receiver members may also be placed on or overengaging portions after engagement of the engaging portions into bone,and may be multi-axial, pivotable or otherwise adjustable with respectto such engaging portions. A connecting member, such as rod R, isinserted into the surgical site, and placed adjacent one or more of theanchors. The anchors and connecting member are manipulated so that apart of the connecting member is in or near the each of the anchors, andsuch manipulation can be accomplished using embodiments of reducinginstruments such as those described above. The instruments may be usedwith a variety of anchors or implants, including those known previouslyin the art and those described above.

During operation, the embodiments of reducing instruments describedabove operate generally similarly to each other, and therefore forsimplicity operation of the embodiment of instrument 220 will bedescribed. These descriptions of operation and those given above applyto other embodiments as well. Instrument 220 engages an implant and rodor other connecting member to insert or seat the connecting member inthe implant. Such operation can include reducing or forcing the rod intothe implant once the rod is positioned adjacent the implant into whichthe rod is to be placed or seated. The distal ends of the arm portionsare placed around the rod and the receiver member of the anchor. Thehandle portions are squeezed together, forcing the distal ends of thearm portions towards each other, and causing the rod and the receivermember to become nearer to each other and eventually for the rod to beinserted into the receiver member. The toothed bar and pawl assemblies,if present, interact to maintain the handle portions squeezed together.Once the rod is positioned, the rod can be locked into the implantanchor. A lever, if provided, can be pressed to disengage the toothedbar from the pawl, and the handle portions can be moved apart (e.g. bysprings, if present) to enable removal of instrument 220 from thesurgical site. Thus, through squeezing of an embodiment of theinstrument or pivoting of an embodiment of the instrument with respectto an anchor or a receiver member or portion of an anchor, or acombination of the two motions, a rod may be reduced into a channel ofthe anchor or its receiver member.

As described above, the anchors and connecting member may be positionedin or along one or more parts of the spine, including the cervical,thoracic, lumbar and/or sacral portions. Although the use of embodimentsof instruments is described in the above context, such embodiments andothers could be used with a variety of screws, hooks or other fixationimplants, or in connection with orthopedic implants in parts of the bodyother than the spine.

The above embodiments and others may be made of stainless steel, certainhard plastics, or other materials that are compatible with surgicalprocedures and the implants and rods with which they are used. Featuresparticularly described above in connection with one embodiment may beused or incorporated into other embodiments. For example, armconfigurations or distal end configurations shown in one figure could beused in connection with apparatus shown in other figures.

While the invention has been illustrated and described in detail in thedrawings and foregoing description, the same is to be considered asillustrative and not restrictive in character, it being understood thatall changes and modifications that come within the spirit of theinvention are desired to be protected.

1. A rod reducing apparatus comprising: first and second handle elementseach having a proximal portion and a distal end, said handle elementsbeing pivotally connected to each other adjacent said distal ends ofsaid handle elements; at least one spring connected to at least one ofsaid handle elements and between said handle elements, whereby saidhandle elements are biased apart; and first and second arm elements eachhaving a proximal end and a distal end, said arm elements beingpivotally connected to each other between said ends, said proximal endof said first arm element being pivotally connected to said distal endof said first handle element, and said proximal end of said second armelement being pivotally connected to said distal end of said secondhandle element, whereby bringing together said first and second handleelements brings together said distal ends of said arm elements; saiddistal end of said first arm element having at least one extensionportion having a proximal end and a distal end, wherein at least oneengagement member is positioned at said distal end of said at least oneextension portion and configured to contact an orthopedic bone anchorhaving two spaced apart branches defining a channel therebetween sizedto receive a spinal rod; said distal end of said second arm elementhaving a substantially U-shaped portion, said U-shaped portion havingtwo extension portions substantially parallel to said second arm elementand a pair of cross-pieces joining said extension portions with a gapformed between said pair of cross-pieces, said U-shaped portionconnecting to the remainder of said second arm element adjacent one orboth of one of said cross-pieces and one of said extension portions,said extension portions having respective distal ends, said distal endsof said extension portions of said second arm element each including asubstantially part-cylindrical hollow, said hollows being substantiallycoaxial and having a radius equal to or larger than the radius of a thespinal rod; wherein said at least one engagement member defined by saidat least one extension portion of said first arm element is pivotallyengaged with said orthopedic bone anchor at a pivot engagement locationdefining a pivot axis, and wherein said first arm element pivots withrespect to said orthopedic implant at said pivot engagement locationabout said pivot axis, and said first and second arm elements areoperable to force the spinal rod and the orthopedic bone anchortogether, and wherein one of the branches of the orthopedic bone anchoris generally aligned with said gap between said cross-pieces of saidsecond arm element when said spinal rod is positioned within saidchannel.
 2. The apparatus of claim 1, wherein one of said cross-piecesis more proximal to said handle portions and one of said cross-pieces ismore distal from said handle portions, and said more distal cross-pieceincludes a tab portion.
 3. The apparatus of claim 2, wherein said tabportion is at least partially curved.
 4. The apparatus of claim 1,wherein said U-shaped portion of said second arm element is angledtoward said first arm element.
 5. The apparatus of claim 4, wherein saidsecond arm element has a longitudinal axis, and the angle between saidaxis and said U-shaped portion of said second arm element is about 160degrees.
 6. The apparatus of claim 1, wherein said distal end of saidfirst arm element has two extension portions positioned substantiallyparallel to said first arm element and a cross-piece joining saidextension portions, wherein said at least one engagement member includestwo protrusions, each distal end of said two extension portionsincluding one of said protrusions, said protrusions substantially facingeach other.
 7. The apparatus of claim 1, wherein said at least oneengagement member is a single cylindrical portion positioned at saiddistal end of said at least one extension portion of said first armelement.
 8. The apparatus of claim 1, wherein said at least oneengagement member is a piece defining a hollow positioned at said distalend of said at least one extension portion of said first arm element. 9.The apparatus of claim 8, wherein said anchor includes a protrusion,said hollow being configured to receive at least a portion of saidprotrusion.
 10. The apparatus of claim 1, wherein said first and secondarm elements each include a curved portion between said distal andproximal ends of said arm elements, wherein said curved portions open ina direction from one arm element towards the other arm element.
 11. Theapparatus of claim 1, wherein said part-cylindrical hollows each includea circumference of about one-fourth the circumference of a circle.
 12. Arod reducing apparatus comprising: first and second handle elements eachhaving a proximal portion and a distal end, said handle elements beingpivotally connected to each other adjacent said distal ends of saidhandle elements; at least one spring connected to at least one of saidhandle elements and between said handle elements, whereby said handleelements are biased apart; and first and second arm elements each havinga proximal end and a distal end, said arm elements being pivotallyconnected to each other between said ends, said proximal end of saidfirst arm element being pivotally connected to said distal end of saidfirst handle element, and said proximal end of said second arm elementbeing pivotally connected to said distal end of said second handleelement, whereby bringing together said first and second handle elementsbrings together said distal ends of said arm elements; said distal endof said first arm element having at least one extension portion having aproximal end and a distal end, wherein a cylindrical portion ispositioned proximal said distal end of said at least one extensionportion and configured to contact an anchor, said cylindrical portionbeing substantially linear and arranged along a pivot axis positionedsubstantially perpendicular to said at least one extension portion, saidcylindrical portion configured to accommodate a correspondingcylindrical-shaped feature of said anchor, said cylindrical portionpivotably engaged with said cylindrical-shaped feature at a pivotengagement location defining said pivot axis, wherein said first armelement pivots with respect to said anchor at said pivot engagementlocation about said pivot axis; said distal end of said second armelement having a substantially U-shaped portion, said U-shaped portionhaving two extension portions substantially parallel to said second armelement and a pair of cross-pieces joining said extension portions, saidU-shaped portion connecting to the remainder of said second arm elementadjacent one or both of one of said cross-pieces and one of saidextension portions, said extension portions having respective distalends, said distal ends of said extension portions each including asubstantially part-cylindrical hollow, said hollows being substantiallycoaxial and having a radius equal to or larger than the radius of aspinal rod.
 13. The apparatus of claim 12, wherein said first and secondarm elements each include a curved portion between said distal andproximal ends of said arm elements, wherein said curved portions arepositioned in a first plane, both of said handle elements beingpositioned in a second plane, wherein said first and second planes areparallel.
 14. The apparatus of claim 12, wherein said part-cylindricalhollows each include a circumference of about one-fourth thecircumference of a circle.
 15. The apparatus of claim 14, wherein eachof said distal ends of said extension portions of said second armelement includes a straight segment adjacent said part-cylindricalhollow.
 16. The apparatus of claim 12, wherein said extension portion ofsaid first arm element includes a bend of about 90 degrees, saidcylindrical portion being offset from said extension portion in adirection toward said second arm element.
 17. The apparatus of claim 12,wherein said distal end of said first arm element includes two extensionportions substantially parallel to said first arm element and a firstcross-piece joining said extensions portions at said proximal ends,wherein said cylindrical portion is a second cross-piece joining saiddistal ends of said extension portions.
 18. The apparatus of claim 17,wherein the apparatus is used in conjunction with an orthopedic boneanchor having two spaced branches, and said first cross-piece and saidcylindrical portion are separated by a gap sufficient to admit one ofsaid branches.
 19. A rod reduction apparatus comprising: a first armportion adapted to connect to an orthopedic rod, said arm portionincluding two extensions and two cross-pieces substantiallyperpendicular to said extensions, said extensions and said cross-piecesforming a gap, said extensions each having a hollow for accommodatingthe orthopedic rod; and a second arm portion adjacent said first armportion, said second arm portion being adapted to connect to anorthopedic implant having two spaced apart branches defining a channeltherebetween sized to receive the orthopedic rod, said second armportion including one or more extension portions having distal andproximal ends, wherein a cylindrical portion is positioned proximal saiddistal ends and configured to contact the orthopedic implant, saidcylindrical portion pivotally engaged with said orthopedic implant at apivot engagement location defining a pivot axis, wherein said first armelement pivots with respect to said orthopedic implant at said pivotengagement location about said pivot axis substantially parallel to anaxis of said channel; whereby said arm portions are operable to forcethe orthopedic rod and the orthopedic implant together.
 20. Theapparatus of claim 19, wherein one of said cross-pieces of said firstarm portion is adjacent said hollows of said extensions and includes atab portion that is at least partially curved, said curve beingconfigured approximately the same as said hollows.
 21. The apparatus ofclaim 19, wherein said hollows form a substantially quarter-circularsection.
 22. The apparatus of claim 19, wherein said first arm portionincludes two extension portions substantially parallel to said first armportion, wherein said cylindrical portion is a first cross-piece joiningsaid distal ends of said extension portions.
 23. The apparatus of claim22, wherein a second cross-piece joins said proximal ends of saidextension portions, said second cross-piece and said cylindrical portiondefining a gap wide enough to allow a branch of the orthopedic implantto at least partially pass through.
 24. The apparatus of claim 19,wherein said first arm portion includes one extension portion, said oneextension portion including a bend of about 90 degrees so that saidcylindrical portion is offset from said extension portion in a directiontoward said second arm portion.
 25. The apparatus of claim 19, whereinsaid first and second arm portions each include a curved section betweenthe ends of said arm portions, wherein said curved sections open in adirection from one arm portion to the other arm portion.
 26. Anapparatus for reducing an elongated member to an orthopedic implanthaving a channel for receiving the elongated member, comprising: a firstportion adapted to be connected to the implant, said first portion beingpivotable with respect to the implant around an axis substantiallyparallel to an axis of the implant channel when said first portion isconnected to the implant; a second portion adapted to contact the rod,said second portion being connected to said first portion so that saidportions can be forced generally toward each other, wherein when saidsecond portion contacts the rod, forcing said portions generally towardeach other urges the rod generally toward the implant, and pivoting saidfirst portion around the implant urges said rod toward general alignmentwith the implant channel; wherein when said second portion contacts therod and the implant is connected to a bone, forcing said portionsgenerally together pushes the rod generally parallel to a bone surface,and pivoting said first portion around the implant pushes the rodgenerally perpendicular to the bone.
 27. A rod reduction apparatuscomprising: a first arm portion adapted to connect to an orthopedic rod,said arm portion including two extensions and two cross-piecessubstantially perpendicular to said extensions, said extensions and saidcross-pieces forming a gap, said extensions each having a hollow foraccommodating the orthopedic rod; and a second arm portion adjacent saidfirst arm portion, said second arm portion being adapted to connect toan orthopedic implant having two spaced apart branches defining achannel therebetween sized to receive the orthopedic rod, said secondarm portion including one or more extension portions having distal andproximal ends, wherein a cylindrical portion is positioned proximal saiddistal ends and configured to contact the orthopedic implant, saidcylindrical portion pivotally engaged with said orthopedic implantwherein said first arm element pivots with respect to said orthopedicimplant about a pivot axis substantially parallel to an axis of saidchannel, wherein said cylindrical portion is substantially linear and ispositioned substantially perpendicular to said one or more extensionportions; whereby said arm portions are operable to force the orthopedicrod and the orthopedic implant together.
 28. A rod reduction apparatuscomprising: a first arm portion adapted to connect to an orthopedic rod,said arm portion including two extensions and two cross-piecessubstantially perpendicular to said extensions, said extensions and saidcross-pieces forming a gap, said extensions each having a hollow foraccommodating the orthopedic rod; and a second arm portion adjacent saidfirst arm portion, said second arm portion being adapted to connect toan orthopedic implant having two spaced apart branches defining achannel therebetween sized to receive the orthopedic rod, said secondarm portion including one or more extension portions having distal andproximal ends, wherein a cylindrical portion is positioned proximal saiddistal ends and configured to contact the orthopedic implant, saidcylindrical portion pivotally engaged with said orthopedic implantwherein said first arm element pivots with respect to said orthopedicimplant about a pivot axis substantially parallel to an axis of saidchannel, wherein said cylindrical portion is configured to accommodate acorresponding cylindrical-shaped feature of said orthopedic implant,said cylindrical portion pivotally engaged with said cylindrical-shapedfeature wherein said second arm portion pivots with respect to saidorthopedic implant about said pivot axis; whereby said arm portions areoperable to force the orthopedic rod and the orthopedic implanttogether.
 29. An apparatus for reducing an elongated member to anorthopedic implant having a channel for receiving the elongated member,comprising: a first portion adapted to be connected to the implant, saidfirst portion being pivotable with respect to the implant around an axissubstantially parallel to an axis of the implant channel when said firstportion is connected to the implant; a second portion adapted to contactthe rod, said second portion being connected to said first portion sothat said portions can be forced generally toward each other, whereinwhen said second portion contacts the rod, forcing said portionsgenerally toward each other urges the rod generally toward the implant,and pivoting said first portion around the implant urges said rod towardgeneral alignment with the implant channel; wherein said first portionis pivotally engaged with said implant to provide said pivoting of saidfirst portion around said implant and wherein said first portionincludes at least one pivot engagement member arranged along a pivotaxis substantially parallel to said axis of said implant channel, saidat least one pivot engagement member pivotally engaged with acorresponding portion of said implant at a pivot engagement locationdefining said pivot axis, and wherein said at least one pivot engagementmember pivots with respect to said implant at said pivot engagementlocation about said pivot axis.
 30. The apparatus of claim 29, whereinsaid first portion is a part of a first arm, said second portion is apart of a second arm, said arms being hingedly connected, and furthercomprising a handle portion including one or more handle elements, saidhandle portion connected to said arms so that activating said handleportion forces said end portions of said arms generally toward eachother.
 31. The apparatus of claim 29, wherein when said second portioncontacts the rod and the implant is connected to a bone so that theimplant extends in a first direction away from the bone, forcing saidportions generally toward each other pushes the rod generally obliquelyor perpendicularly with respect to said first direction, and pivotingsaid first portion around the implant pushes the rod in a directionhaving at least a component that is parallel to said first direction.